Basic Information
| Provider Information | |||||||||
| NPI: | 1285231258 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STIDAM | ||||||||
| FirstName: | ALICIA | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | APRN, FNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 41 HOMEPLACE WAY | ||||||||
| Address2: | |||||||||
| City: | MOREHEAD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403519071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067845894 | ||||||||
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| Practice Location | |||||||||
| Address1: | 245 FLEMINGSBURG RD | ||||||||
| Address2: | |||||||||
| City: | MOREHEAD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403511015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067805500 | ||||||||
| FaxNumber: | 6067837281 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2020 | ||||||||
| LastUpdateDate: | 03/18/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 3015232 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 3015232 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 3015232 | 01 | KY | KY MEDICAL LICENSE | OTHER |